Clinical depression is a very serious mental condition bringing untold misery to millions and, being strongly linked to suicide, depression, if not properly managed can be fatal and too often is. Yet we are not good it seems at managing clinical depression and it’s not really anyone’s fault rather it’s a failure in a systems approach that has attempted to standardise treatment, something generally good in itself, but in depression, sadly, maybe making things worse. The paradigm of current management is now a set of guidelines and in the UK this is the NICE guidelines (1) . These are very good, comprehensive and detailed but for a busy GP or non-medical prescriber they are challenging to comply with when your time poor and faced with a potentially depressed patient.
There seems to be three emerging problems with our current approach. Firstly we have such a low bar when it comes to diagnosing depression that perhaps a high percentage of those currently with a diagnosis may not have the condition at all. Most people on a series of bad days over a 2 week period can end up with a depression diagnosis when they really only have low mood which will quickly resolve if left alone with reassurance. The second issue is that the medicines used to treat depression, more specifically the SSRIs and SNRIs, (Prozac and Effexor for example) are generally ineffective when used to treat mild to moderate depression only being effective in more severe cases of the condition which might be those cases that are more rightly identified as the truly clinically depressed. And linked to this is the third issue that antidepressant drugs used widely, if not indiscriminately, have some pretty nasty side-effects that can significantly reduce quality of life and may even hold back recovery.
It seems that at this point in time our approach to the management of depression is facing such a challenge on these three issues that in coming years we might look back and wonder how we had been so cruel to those suffering and in need. The solution is to invest, to support better mental resilience not in the medical model but in a societal model. The solution is in strong communities, resilient individuals and supported families. I’m saying nothing new and this lack of investment in mental health has been recognised for years.
A recent paper in the journal Molecular Psychiatry has attracted considerable attention in that it seems to have finally put to bed the theory that depression is caused by a chemical imbalance, a lack of serotonin in the brain (2). https://www.nature.com/articles/s41380-022-01661-0. The chemical imbalance theory comes from the 1970s if not before and I am of a generation that was taught this at University. But the interest in this recent paper I find surprising as twenty years ago this theory was being challenged as much too simplistic. The fact that medicines, the selective-serotonin-reuptake-inhibitors (SSRIs), could replace a deficiency of this neurotransmitter in the brain was fanciful yet was a great marketing line for the drug companies who made fortunes on fluoxetine (Prozac) and then a series of others in the SSRI class. To say that the human brain is a complex organ is to make the ultimate understatement. But what is clear from the Molecular Psychiatry paper is that on five levels there is now conclusive proof that the neurotransmitter serotonin is not deficient in the brains of people with depression.
The SSRIs are much less effective than is appreciated, and the placebo effect in depressive conditions for these drugs is about 80%. Just giving the depressed patient some care and attention and some follow-up itself can be very therapeutic.
But SSRIs are not just sugar-pill placebos they do have pharmacological effects. And these effects are sometimes responsible for debilitating side effects. Patients can often report living in limbo in a twilight world where they just don’t care but they can get through. The drugs have a significant social impact for example they can severely affect sexual activity and it impact on relationships. Withdrawal from SSRIs can be severe and must be done under medical supervision therefore anyone reading this must not stop their SSRIs but speak to their GP or mental health professional before attempting to do so. A recent article by P. Mosowitz in The Nation covers the list of side effects and suggests we deserve a fuller picture of both the benefits and dangers of antidepressants (3). The writer Johann Hari in his book Lost Connections gives a very personal account of fighting depression and his need to address his antidepressant use as a means of moving on (4).
For all of the 9 causes of depression & anxiety, there are solutions like this. pic.twitter.com/d2fyAauCMb
— Johann Hari (@johannhari101) August 10, 2022
I have been deeply annoyed by a series of deaths by suicide in young people in West Belfast over recent weeks. These deaths are not reported and rightly so but they are a barometer of our failure as a society when it comes to supporting those with mental health problems. And where that just sounds like a cliche the resolution is in doing the hard things like; destigmatizing mental health, making the necessary mental health service investments, recognising and supporting those who are struggling but also supporting personal resilience. We all need to see more creative ways for individuals to adopt the Take Five Message. Our personal mental health is so much better when; we give more, are more curious, keep learning every day, take more exercise and connect with our communities, families and friends (5). https://www.publichealth.hscni.net/publications/take-5-steps-wellbeing-english-and-11-translations. There is also a need to more widely provide Cognitive Behavioural Therapy (CBT) and other Talking Therapies which are effective and which builds personal resilience.
I am a pharmacist in Belfast.
